NTSB Factual Report

HISTORY OF FLIGHT

On August 25, 2012, about 1530 eastern daylight time, a Schleicher ASW-19 glider, N438AS, sustained substantial damage when it collided with terrain in Dansville, New York. The commercial pilot received fatal injuries. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight originated from the Dansville Municipal Airport (DSV), Dansville, New York, about 1230.

The pilot owned the glider and based it at DSV. He was also a member of Finger Lakes Soaring (FLS), which was based at DSV. Two witnesses observed the accident. The first witness was working at a facility near the airport. He reported that he was watching the glider perform large circles. The glider then started rolling, "back and forth from one wing to another." After three or four rolls, the glider descended nose-down to the ground in a 90-degree bank attitude. The second witness was another member of FLS and was at the airport. He stated that he was standing near the front entrance of the clubhouse when he observed the glider about 1 mile north of the airport. The glider was in a 90-degree bank and flying west at a slow speed, about 30 knots. The glider then turned north and the bank seemed to decrease, but the glider descended into terrain.

PILOT INFORMATION

The pilot, age 66, held a commercial pilot certificate with ratings for airplane single-engine land and glider. He also held a flight instructor certificate, with a rating for glider. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on July 14, 2011. At that time, he reported a total flight experience of 1,600 hours. The pilot's logbook was not recovered.

AIRCRAFT INFORMATION

The single-seat, fiberglass and metal glider, serial number 19230, was manufactured in 1978. It's most recent annual inspection was completed on August 18, 2012. At that time, the glider had accumulated 1,159.2 total flight hours.

Another FLS member added that the glider had not flown for about 5 years prior to the accident. The pilot had the glider resurfaced and returned to service, which was completed about 5 days prior to the accident. The evening prior to the accident, the glider was assembled and flown by the pilot for about 30 minutes uneventfully.

METEOROLOGICAL INFORMATION

The recorded weather at DSV, at 1554, was: wind from 210 degrees at 7 knots; visibility 10 miles; sky clear; temperature 31 degrees C; dew point 14 degrees C; altimeter 30.18 inches Hg.

WRECKAGE INFORMATION

The glider impacted a field about 1 mile northwest of DSV. Examination of the wreckage by an FAA inspector revealed that the landing gear was in the down and locked position. The right wing had separated from the spoiler box outward, and the left wing exhibited impact damage on its underside and at the wing tip. The forward section was compromised and crushed back into the cockpit area. The canopy assembly was opened, but remained attached to the fuselage with the Plexiglas broken and shattered throughout the debris field. The tailboom was partially separated and bent toward the right of the glider. Flight control continuity was established during the examination.

After the wreckage was recovered from the field, the static balance of the flight controls was tested at a repair facility. The testing revealed that the elevator (7.3 in./lbs. with an allowable range of 5.21 to 8.81 in./lbs.) and ailerons (8.8 in./lbs. with an allowable range of 7.59 to 9.33 in./lbs.) were within limits. The rudder (12.1 in.\lbs. with an allowable range of 7.81 to 10.41 in./lbs.) was out of balance; however, the preimpact weight and balance of the flight controls could not be determined and there was no evidence that the rudder imbalance resulted in a loss of roll control.

A ClearNav MN-1365 flight display was recovered from the wreckage and forwarded to the NTSB Vehicle Recorder Laboratory, Washington, D.C. Data were successfully downloaded from the unit, but the data were from three previous events. The first two events were recorded on June 19 and July 28, 2012. They were recorded on the ground and consistent with unit installation or maintenance and not a flight. The third event recorded was recorded on August 24, 2012, which was the uneventful flight that was completed during the evening prior to the accident. The accident flight was not recorded.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Monroe County Medical Examiner's Office, Rochester, New York. Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. Review of the toxicological report revealed:

"Diphenhydramine detected in Liver

0.488 (ug/ml, ug/g) Diphenhydramine detected in Blood (Cavity)

Metoprolol detected in Liver

Metoprolol detected in Blood (Cavity)"

Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under the trade names Benadryl and Unisom. Compared to other antihistamines, diphenhydramine causes marked sedation; it is also classed as a depressant and this is the rationale for its use as a sleep aid. Altered mood and impaired cognitive and psychomotor performance may also be observed. In fact, in a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100 percent.

Review of the pilot's FAA medical records revealed that in 2009, he underwent a procedure to repair an aneurysm of the ascending aorta combined with placement of a single vessel coronary artery bypass graft. In 2011 he applied for a medical certificate and reported the surgery and that he was taking metoprolol (a beta blocker used to treat hypertension and prevent heart attacks), simvastatin (a cholesterol lowering drug), and lisinopril (a blood pressure medicine). After providing additional information, he was awarded a third-class special issuance medical certificate "not valid for any class after 7/31/2012."

At the time of the accident, his medical was no longer valid, but he was flying a glider which only required him to "self-certify" his medical condition. According to the autopsy report, the cause of death was multiple blunt force injuries. Natural disease of the heart was also noted including atherosclerotic heart disease and hypertensive heart disease with dilation and enlargement of the heart. The previous coronary artery bypass graft and aortic repair were described by the pathologist.

The pilot's friend and fellow club member reported that the pilot stated he was not feeling well on the day of the accident. The friend added that the day was hot and although the pilot drank coffee prior to the flight, he did not drink water or bring any water with him on the flight.

NTSB Probable Cause

The pilot’s failure to maintain glider control while maneuvering. Contributing to the accident was the pilot’s impairment due to an over-the-counter sedating antihistamine.